San Francisco General Hospital & Trauma Center The … 11/201… · San Francisco General Hospital & Trauma Center The Joint Commission, ICM OPTION 2 SURVEY COMPREHENSIVE QUALITY

San Francisco General Hospital & Trauma Center The Joint Commission, ICM OPTION 2 SURVEY COMPREHENSIVE QUALITY MONITORING TOOL

KEY: Tier 3 - Direct impact | Tier 4 - Indirect impact | M – Measure of Success (MOS) Page 1 of 65

STANDARD/EP ACTION PLAN – WHAT/WHEN/HOW MOS GOAL

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EC.01.01.01: EP 3, Tier 4, A, D, R (pg 55 of 86): The hospital has a written plan for managing the following: The environmental safety of patients and everyone else who enters the hospital's facilities. (See also EC.04.01.01, EP 15) EP 4, Tier 4, A, D, R (pg 55 of 86): The hospital has a written plan for managing the following: The security of everyone who enters the hospital's facilities. (See also EC.04.01.01, EP 15) Organization findings (pg 56 of 86): EP 3 There was not a written plan for managing the environment of care related to patient safety and everyone else who entered the hospital's facilities which addressed specific relevant issues. The plan that was reviewed was generic and non-specific with no information built in from the previous year's evaluation of the plan.

Hospital leadership updated the 2012-2013 SFGH Environment of Care Report to address the plan for managing the environment of care related to safety and to security including performance metrics. The revised report was approved by hospital leadership and the Governing Body Joint Conference Committee effective January 2014. Hospital leadership reviewed and revised the Environment of Care (EOC) Committee membership to ensure representation by appropriate staff, including SFSD staff, and to ensure committee reporting structure. SFSD, as a contracted service with the CCSF-DPH, is a participant on the key hospital committees addressing campus safety & security issues: 1. Administrative Operations Meeting 2. Bed Meetings 3. Critical Incident Response Team 4. Code Green Task Force (At-Risk Missing Patients) 5. Disaster Council Committee 6. Employee Health & Safety 7. Environment of Care (EOC) Committee 8. Hospital Leadership Security Meeting 9. Infant/Child Security Program Committee (Code Pink) 10. Management Forum 11. Violence Prevention Team

Lann Wilder Kath Jung Tom Holton Capt. Farrigno




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Hospital and SFSD leadership reinforced the expectation that SFSD representatives attend and are actively involved on key hospital committees addressing campus safety and security issues and will verify SFSD representatives attendance at committee meetings.

EP 4 There was not a written plan for managing the environment of care related to security which addressed specific relevant issues. The plan that was reviewed was generic and non-specific with no information built in from the previous year's evaluation of the plan.

Hospital leadership updated the 2012-2013 SFGH Environment of Care Report to address the plan for managing the environment of care related to safety and to security including performance metrics. The revised report was approved by hospital leadership and the Governing Body Joint Conference Committee effective January 2014. Hospital leadership reviewed and revised the Environment of Care (EOC) Committee membership to ensure representation by appropriate staff, including SFSD staff, and to ensure committee reporting structure. SFSD, as a contracted service with the CCSF-DPH, is a participant on the key hospital committees addressing campus safety & security issues: 1. Administrative Operations Meeting 2. Bed Meetings 3. Critical Incident Response Team 4. Code Green Task Force (At-Risk Missing Patients) 5. Disaster Council Committee 6. Employee Health & Safety 7. Environment of Care (EOC) Committee 8. Hospital Leadership Security Meeting 9. Infant/Child Security Program Committee (Code Pink) 10. Management Forum 11. Violence Prevention Team

Lann Wilder Kath Jung Tom Holton Capt. Farrigno




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Hospital and SFSD leadership reinforced the expectation that SFSD representatives attend and are actively involved on key hospital committees addressing campus safety and security issues and will verify SFSD representatives attendance at committee meetings.

EC.02.01.01, EP 1, Tier 4, A, R (pg 57 of 86): The hospital identifies safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital's facilities. Note: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of annual proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts. (See also EC.04.01.01, EP 14)

Organization findings (pg 58 of 86): EP 1 It was found that the sharps disposal box in a patient room on telemetry floor was found at a height/level where it could be reached into by a child

SHARPS: Facilities staff raised the sharps disposal box in the patient room on the telemetry floor off of the floor and mounted it on the wall.

Leslie Dubbin

EP 1 Room 4C34 used to be an office, but is now a treatment area on the Outpatient Infusion Center. The door has a key pad access. Patients in this room could be put at risk if someone could not enter the room if needed.

KEY PAD: The Facility locksmith removed the keypad to Room4C34 replaced it with a regular key lock.

Leslie Dubbin

EP 1 Zone 3 of MRI is not restricted screened area as defined by org. Law enforcement officer was seen in Zone 3 who as per org was not screened prior to entry to zone 3.Interview with lab aide who has access to zone 3 could not identify all MRI zones. The door to zone 4 was wide open during surveyor visit.

,RI: Following the ICM survey, Radiology leadership took the following actions: *determined and established MRI safety zones as recommended by American College of Radiology (ACR) for MRI Safe Practices 2013; completed 12.18.13 *established map of the MRI Safety Zones; completed 12.18.13 *changed 02 tank to non- ferrous MRI safe tank; Completed 12.16.13

Shermineh Jafarieh David Sostarich Ed Ochi




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*added temporary barrier device for Non-ferrous bright yellow chain between zone 2 and zone 3; completed 1.14.14 *additional and proper signage added to areas to assure zone identification; completed 1.13.14 *reviewed in house fire safety with the SFGH Fire Marshall; completed 12.19.13 *Radiology Leadership to work with EOC to review MRI safety policies with CCSF Sheriff and Fire Department to ensure safety plan; complete by 2.28.14 *revised and updated Department of Radiology MRI Safety Manual (Draft completed for review by EOC); 12.23.13 *document will be finalized and approved by Radiology Department Leadership: by 2.21.14 *Radiology Staff Education on Zone and Zone Safety to be completed by 1.30.14 *relocate dressing area to Zone 2 from Zone 3; work order submitted to Facilities on 1.1414 *initiated staff screening tool for non-radiology staff that need to enter zone 3 or 4; completed on 1.14.14 *move patient registration for MRI (previously in Zone 2) to Radiology Window 2 where only screening patients and staff will have access to Zone 2; to be completed by 2.28.14 *add permanent barrier to entrance of Zone 3 to assure proper management of flow through this area; work order submitted to facilities 1.14.14




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*ensure hospital wide knowledge and training of MRI safety by inserting updated MRI safety policies in hospital continuing education (Halogen EOC module) and staff orientation (through DET); to be completed by 2.28.14

EC.02.03.01, EP 1, Tier 3, C, R (pg 59 of 86): The hospital minimizes the potential harm from fire, smoke, and other products of combustion.

Organization findings (pg. 59 of 86): EP1 Prevantix Maxiswabstix which is an alcohol based swab as per staff when asked about dry time was 60 seconds against manufacturers’ instructions of 90 seconds. Also further clarification with staff in intervention radiology area revealed that the dry time as specified by manufacturers instruction was not the norm.

Following the ICM survey, Radiology Service implemented the following: "Educated IR staff re: proper use of Prevantix MaxiSwabstick via unit meetings and newsletters on 1.9.14; each individual who performs prep is evaluated via return demonstration - completed 1.17.14. "Placed laminated posters in each procedure room that show proper steps for use of prep stick; laminated posters hung on 1/13/2014. *IR staff who perform patient skin preparation will have 'proper skin prep" practice added to competency evaluation and it will be assessed on initial and annual competency checklist. Will monitor staff usage of Prevantix MaxiSwabstic weekly for a period of 1 month. Compliance will be reported as: Numerator: Number of IR procedure patients who had skin preparation completed correctly without intervention. Denominator: All IR procedure patients needing skin prep Goal: 100% compliance Numerator: Number of IR personnel observed who performed skin preparation correctly.

Elaine Dekker Lann Wilder Ed Ochi Kathy Jung Patty Coggan Kathy Ballou Shermineh Jafarieh David Sostarich Mark Wilson




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Denominator: All IR personnel who are responsible for performing patient skin prep. Goal: 100% of personnel will have initial evaluation by the end of 1 month

EC.02.05.01: EP 2, Tier 4, A, D (pg 60 of 86): The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems). The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory. (See also EC.02.05.05, EPs 1, 3-5) EP 6, Tier 3, A, R (pg 61 of 86): In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies. Note: Areas designed for control of airborne contaminants include spaces such as operating rooms, special procedure rooms, delivery rooms for patients diagnosed with or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis), patients in "protective environment" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms. For further information, see Guidelines for Design and Construction of Health Care Facilities, 2010 edition, administered by the Facility Guidelines Institute and published by the American Society for Healthcare Engineering (ASHE). Organization findings (pg 62 of 86): EP 2 Noted that the inventory list for the monitoring of air ventilation did not include the Sterile Processing Department, soiled utility rooms, or the endoscopy decontamination area. These areas had not been monitored or tested for proper air ventilation and relationship.

SPD, soiled utility rooms, endoscopy decontam areas not included on inventory list for monitoring of air ventilation: Following the 1CM Survey, the Chief Engineer physically walked to every room in the main hospital to verify room usage and create inventory. Effective 1/7/2014, the Chief Engineer compiled the Air Pressure Relationship inventory for the Main Hospital, work order 605195. System set to generate an annual work order to verify room usage for air pressure relationships.

Kathy Jung Max Bunuan Elaine Dekker Lann Wilder Greg Chase

EP 6 Noted that 3 operating room suites had air exchanges tested to less than 12 exchanges per hour.

3 ORs ACH less than 12 exchanges per hr: Following the ICM survey, the Director of Facilities contacted the Joint Commission Standards Interpretation Group (SIG) on 12/12/13 for a consultation; on 12119/13,

Kathy Jung Max Bunuan Elaine Dekker Lann Wilder Greg Chase




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SIG directed him to contact the regional OSHPD office and check if they would accept the design standard at the time of permitting. The OSHPD consultant wrote reported that the 2010 California Mechanical Code (CMC) required a minimum of twelve (12) ACH for ORs if it is 100% outside air system. He stated that if the Joint Commission is asking for 15 ACH, they are probably applying ASHRAE Standard 170 of which only 3 ACH have to be OSA for a Class A OR. California does not adopt this standards. SFGH complies with the current CMC requirements. The Chief Engineer made air system adjustments and currently 1 OR is below the required 12 ACH. Need vendor assist to balance the air system and achieve the required 12 ACH for all ORs. Projected completion date, 2/28/2014, work order 605198. System set to generate an annual work order to verify required ACH in Ors.

EC.02.05.05, EP 4, Tier 3, A, D, R (pg 62 of 86): The hospital Inspects, tests, and maintains the following: Infection control utility system components on the inventory. These activities are documented. (See also EC.02.05.01, EPs 2-4)

Organization findings (pg 63 of 86): EP 4 Air flow in the endoscope cleaning room was found positive by tissue test which was confirmed by differential pressure monitor. It was confirmed with facilities management that air exchanges were not conducted at this area since they were not included in the inventory.

Effective 12/19/13, the Chief Engineer adjusted the air pressure relationship in the endoscopy cleaning room—room is now negative compared to the corridor, work order 605183. Effective 1/7/14, the Chief Engineer created the Air Pressure Relationship inventory for the main hospital, work order 605195. System is set to generate an annual work order to verify room usage for air pressure relationships.

Max Bunuan Kathy Jung Lann Wilder Greg Chase Ditas Hernandez

EC.02.05.09, EP 3, Tier 4, A (pg 64 of 86): The hospital makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control.




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Organization findings (pg 64 of 86): EP 3 Noted that an oxygen shut-off valve located in the anesthesia work room was obstructed by a supply cart and shelving for supplies.

OXYGEN SHUT-OFF VALVE: Effective 12119/13, the Chief Engineer met with staff in affected areas to clear obstructions from the immediate area in front of 02 shutoff valves. Work order submitted to manufacture appropriate signage for 02 shutoff valves - work order 606140. Anticipate posting signage by 2128/2014. Compliance with requirement that 02 shutoff valves are not blacked to be verified via EOC rounds. The Anesthesia Workroom Manager created a clearance area with tape on the floor below the shut-off valve to identify the floor space in front of the shut-off valve which should not be obstructed by carts. Removal of shelves around the shut-off valve, and taping of clearance space on floor below the valve, will ensure that the area is not blocked in any way. Reeducation and reminders will be sent out to anesthesia staff If area in front of valve is found blocked by storage/carts. Anything found blocking the shutoff valve will be removed immediately and staff re-educated about the policy.

Kathy Jung Max Bunuan Rich Elliot Greg Chase Lann Wilder Kathy Ballou Kyra Quon

EP 3 Noted that a medical gas shut-off valve located in a C-Section OR room was obstructed by a trash receptacle.

MEDICAL GAS SHUT-OFF Effective 12/19113, the Chief Engineer met with staff in affected areas to clear obstructions from the immediate area in front of 02 shutoff valves. Work order submitted to manufacture appropriate signage for 02 shutoff valves - work order 606140. Anticipate posting signage by 2/28/2014. Compliance with requirement that 02 shutoff valves are not blocked to be verified via EOC rounds.

Kathy Jung Max Bunuan Rich Elliot Greg Chase Lann Wilder Kathy Ballou Kyra Quon

EC.02.06.01: EP 1, Tier 4, C, R, M (pg 66 of 86): Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. EP 20, Tier 3, C, R, M: Areas used by patients are clean and free of offensive odors.




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Organization findings (pg 67 of 86): EP 1 It was found that the light fixture screen in the ceiling in cardiac cath area was found with a large stain suggesting by the color of a water stain

LIGHT FIXTURE STAIN: Facilities staff cleaned light fixture diffuser, work order 605030, completed 12/10/2013. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)

Kathy Jung Francisco Saenz Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston

EP 1 Thick layer of dust was found over the top of Omnicell in the cardiac cath room

DUST ON OMNICEL CABINET: Environmental Services removed the thick layer of dust from the top of the Omnicell on 12/10/2013. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating





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suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)

EP 1 Blinds in the Outpatient Infusion Center and in the lounge on 5A were broken. This was both unsightly and a potential safety risk.

BROKEN BLINDS: Facilities staff removed and replaced the broken blinds from 4C Infusion Center and 5A Solarium/room 5A24 - work order 605020; completed 1/13/2014. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)


Organization findings (pg 67 of 86): [CONTINUED] EP 1 There was a hole in a ceiling tile in room 4F34 (a clean storage area for respiratory therapy supplies).

HOLE IN CEILING: Facilities staff replaced damaged ceiling tiles in room 4F34, work order 605291, completed 12/20/2013. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain)





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EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)

EP 1 The acute psychiatric inpatient unit does not have monolithic ceiling which presents a risk for patients getting into the ceiling and have access to serious hazards. It also creates an opportunity for hiding contraband.

MONOLITHIC CEILING: Changing the splined ceilings to monolithic ceilings requires an OSHPD project permit. Earliest estimated completion date is 9/30/2014. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)


EP 1 During a tour of the Psychiatric Emergency Service it was noted that there is exposed toilet plumbing as well as

EXPOSED PLUMBING (PES): Facilities staff submitted work order to purchase and install suicide prevention plumbing

Kathy Jung Francisco Saenz




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sink faucets and spouts which allow for looping of materials that could create a suicide risk.

covers. Estimated completion date 2/28/2014, work order 606184. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)

Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston

Organization findings (pg 67 of 86): [CONTINUED] EP 1 During a tour of the Psychiatric Inpatient Units it was noted that there is exposed toilet plumbing as well as sink faucets and spouts (in multiple bathrooms) which allow for looping of materials that could create a suicide risk.

EXPOSED PLUMBING (INPT. UNIT): Facilities staff submitted work order to purchase and install suicide prevention plumbing covers. Estimated completion date 2/28/2014, work order 606184. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk)





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EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)

EP 20 During a tour of the Psychiatric Emergency Service it was noted that there was strong odor of urine in a vacant seclusion room.

URINE ODOR: Environmental Services removed the strong urine odor in PES seclusion room on 12/10/2013. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)


EP 1 Noted in the dialysis unit that the floors were very old and very difficult to clean. The water room was very small and there was limited ability to access valves and water treatment controls. Due to the physical constraints within the patient care area there was high risk for cross-contamination of infection control concerns. In addition, fire evacuation routes involved numerous flights of stairs and the mode of patient evacuation may require the use of blankets. This method of evacuation had never been tested. The organization stated that there were numerous identified building code noncompliance issues.

DIALYSIS: The building where the Renal Service Outpatient Chronic Dialysis unit is located is close to one hundred years old. Hospital leadership has been in process of reviewing relocation options; this is a long-term project - recommendations are under review. The Chief Engineer met with the Renal Service Outpatient Chronic Dialysis unit leadership to formulate a plan for floor repair; estimated completion date is 3/14/2014. The Infection Control Program Manager met with Renal Service Outpatient chronic Dialysis unit leadership staff to review infection control practices to prevent cross-contamination. The SFGH

Kathy Jung Max Bunuan Elaine Dekker Leslie Dubbin




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Fire Marshall and the SFGH Disaster Coordinator will meet with Renal Service Outpatient Chronic Dialysis leadership to develop simulation evacuation drill and schedule accordingly. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested)

EC.04.01.01, EP 15, Tier 3, A, R (pg 69 of 86): Every 12 months, the hospital evaluates each environment of care management plan, including a review of the plan's objectives, scope, performance, and effectiveness. (See also EC.01.01.01, EPs 3-8; EC.04.01.03, EP 1)

Organization findings (pg 69 of 86): EP 15 There was no documentation of the evaluation for each of the environment of care management plans.

Hospital leadership updated the 2012-2013 SFGH Environment of Care Report. Hospital leadership restructured the Environment of Care Committee as a multidisciplinary leadership committee with representatives from Nursing, Infection Control, Clinical Laboratory, Pharmacy, Environmental Services, and Quality Management. Membership includes program managers for each of the six EOC management programs: Safety, Security, Hazardous Materials & Waste, Medical Equipment, Utilities & Fire Life Safety, and Emergency Management. The EOC

Kathy Jung Lann Wilder Tom Holton




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Committee is now co-chaired by the Associate Administrator for Support Services and the Patient Safety Officer. The EOC Committee reports quarterly to the hospital-wide Quality Council. The EOC Committee is charged with developing additional performance metrics and tracking mechanisms to more effectively capture key information to be included in the annual evaluation of the EOC management plans.

HR.01.02.05, EP 5, Tier 4, C, D, R, M (pg 70 of 86): Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented.

Organization findings (pg 70 of 86): EP 5 The personnel file of an RN who recently returned from a one year LOA was reviewed. It was noted that she did not have a fit test done, even though she was due for annual fit testing. It was further identified that Employee Health staff are not notified when a staff member returns from an LOA so that any required health screening can be completed.

The Employee Health Service (EHS), in collaboration with Environmental Health and Safety and Infection Control, has drafted a matrix to identify employees working on the SFGH campus who are required to be fit tested for a N95 Respirator. Annual Fit Testing will be conducted for each work area where staff are identified in the matrix as requiring respirators. The fit testing the same month as the work area's annual TB surveillance. Respirator Fit Testing compliance will be included on the monthly OHS report that is compiled for TB surveillance statistics. It will be the manager's responsibility to ensure that all employees identified in the matrix as requiring respirators are compliant with Fit Testing. The manager will notify EHS when an employee returns from a leave of absence or is in an As Needed status such as a P103 and is not current with their Fit Testing. EHS staff will collaborate with UCSF Employee Health to develop a mechanism to ensure the identification of UC

Ron Weigelt Leslie Dubbin Terry Dentoni Tom Holton Aiyana Johnson Ed Ochi Maggie Rykowski




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employees working on the SFGH campus and their compliance with annual fit testing. MOS: The Director of Occupational Health or designee(s) will monitor compliance with requirements to be fit tested with an N95 respirator for four consecutive months. Numerator: the number of staff compliant with annual N95 fit testing. Denominator: the number of employees required to be fit tested for a N95 respirator. The OHS N95 Fit Testing & TB Surveillance results will be reported monthly for one quarter to Infection Control Committee and to the Accreditation, Licensing, Certification Committee (ALCC). The N95 Fit Testing and TB Surveillance compliance data will be included in the Infection Control Committee annual report to Quality Council.

EP 5 Noted during personnel file review that a 'fit test' had not been conducted for an anesthesia technician during 2012 and 2013 per organizational policy.

The Employee Health Service (EHS), in collaboration with Environmental Health and Safety and Infection Control, has drafted a matrix to identify employees working on the SFGH campus who are required to be fit tested for a N95 Respirator. Annual Fit Testing will be conducted for each work area where staff are identified in the matrix as requiring respirators. The fit testing the same month as the work area's annual TB surveillance. Respirator Fit Testing compliance will be included on the monthly OHS report that is compiled for TB surveillance statistics. It will be the manager's responsibility to ensure that all

Ron Weigelt Leslie Dubbin Terry Dentoni Tom Holton Aiyana Johnson Ed Ochi Maggie Rykowski




RESPONSIBLE PERSON

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employees identified in the matrix as requiring respirators are compliant with Fit Testing. The manager will notify EHS when an employee returns from a leave of absence or is in an As Needed status such as a P103 and is not current with their Fit Testing. EHS staff will collaborate with UCSF Employee Health to develop a mechanism to ensure the identification of UC employees working on the SFGH campus and their compliance with annual fit testing. MOS: The Director of Occupational Health or designee(s) will monitor compliance with requirements to be fit tested with an N95 respirator for four consecutive months. Numerator: the number of staff compliant with annual N95 fit testing. Denominator: the number of employees required to be fit tested for a N95 respirator. The OHS N95 Fit Testing & TB Surveillance results will be reported monthly for one quarter to Infection Control Committee and to the Accreditation, Licensing, Certification Committee (ALCC). The N95 Fit Testing and TB Surveillance compliance data will be included in the Infection Control Committee annual report to Quality Council.

EP 5 Noted during HR file review of an ED RN that a fit test that was due in Feb 2013 was not done.

The Employee Health Service (EHS), in collaboration with Environmental Health and Safety and Infection Control, has drafted a matrix to identify employees working on the SFGH campus who are required to be fit tested for a N95 Respirator.

Ron Weigelt Leslie Dubbin Terry Dentoni Tom Holton Aiyana Johnson Ed Ochi




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COMPLIANT DATE

Annual Fit Testing will be conducted for each work area where staff are identified in the matrix as requiring respirators. The fit testing the same month as the work area's annual TB surveillance. Respirator Fit Testing compliance will be included on the monthly OHS report that is compiled for TB surveillance statistics. It will be the manager's responsibility to ensure that all employees identified in the matrix as requiring respirators are compliant with Fit Testing. The manager will notify EHS when an employee returns from a leave of absence or is in an As Needed status such as a P103 and is not current with their Fit Testing. EHS staff will collaborate with UCSF Employee Health to develop a mechanism to ensure the identification of UC employees working on the SFGH campus and their compliance with annual fit testing. MOS: The Director of Occupational Health or designee(s) will monitor compliance with requirements to be fit tested with an N95 respirator for four consecutive months. Numerator: the number of staff compliant with annual N95 fit testing. Denominator: the number of employees required to be fit tested for a N95 respirator. The OHS N95 Fit Testing & TB Surveillance results will be reported monthly for one quarter to Infection Control Committee and to the Accreditation, Licensing, Certification Committee (ALCC). The N95 Fit Testing and TB Surveillance compliance data will be included in the Infection Control

Maggie Rykowski




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Committee annual report to Quality Council.

HR.01.04.01, EP 4, Tier 4, C, D, R, M (pg 71 of 86): The hospital orients staff on the following: Their specific job duties, including those related to infection prevention and control and assessing and managing' pain. Completion of this orientation is documented. (See also 1C.01.05.01, EP 6; IC.02.01.01, EP 7; 1C.02.04.01, EP 2; RI.01.01.01, EP 8).

Organization findings (pg 71 of 86): EP 4 Noted that initial orientation and competence assessment related to high level disinfection and the recertification method of disinfection was not documented in an individual's competence file. Noted that initial orientation and competence assessment related to the high level disinfection process and use of the Steris equipment for endoscopic equipment was not documented in the competence file of a registered nurse who was involved in the cleaning, decontamination, and re-processing of the equipment. During the review of an RN file, it was noted GC, it was noted that the initial orientation to specific job duties was incomplete.

DISINFECTION COMPETENCIES: The managers of units/work areas where employees perform high level disinfection processes and the Recertification method of disinfection (cleaning, decontamination, and re-processing of medical equipment) will review and revise their employee initial and annual skills/competency checklists to ensure that these skills/competencies are included on the checklists. The managers will then re-assess and evaluate all employees who perform high level disinfection processes and the Recertification method of disinfection (cleaning, decontamination, and re-processing of medical equipment) and document their assessment/evaluation using the revised employee initial and annual skills/competency checklists and submit the completed revised checklists to HR for inclusion in the employee HR file. INCOMPLETE INITIAL ORIENTATION: The Nurse Manager of the unit where the finding occurred will, in collaboration with HR, review the unit's new hire employee files from the past twelve months to ensure that the initial orientation performance evaluations, including skills/competency checklist, are complete and correct any initial orientation performance evaluations, including skills/competency checklists, found to be incomplete. MOS: DISINFECTION COMPETENCIES: The managers of units/work areas where employees perform high level disinfection processes and the Recertification method of disinfection will

100% Ron Weigelt Leslie Dubbin Terry Dentoni Tom Holton Aiyana Johnson Ed Ochi Gillian Otway Terry Dentoni




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re-asses employee skills/competencies to perform these processes and ensure that documentation of the evaluation is complete. Numerator: the number of employees with high level disinfection competencies documented Denominator: the number of employees who perform high level disinfection INCOMPLETE INITIAL ORIENTATION: The Nurse Manager of the unit where the finding occurred will, in collaboration with HR, review the unit's new hire employee files from the past twelve months to ensure that the initial orientation performance evaluations, including skills/competency checklist, are complete and correct any initial orientation evaluations, including skills/competency checklists, found to be incomplete. Numerator: the number of unit new hire employees with complete initial orientation performance evaluations Denominator: all unit new hire employees

IC.02.01.01: EP 1, Tier 4, C, R (pg 45 of 86): The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. EP 2, Tier 3, C, M (pg 46 of 86): The hospital uses standard precautions, ' including the use of personal protective equipment, to reduce the risk of infection. Note: Standard precautions are infection prevention and control measures to protect against possible exposure to infectious agents. These precautions are general and applicable to all patients. Footnote *: For further information regarding standard precautions, refer to the website of the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/hait (Infection Control in Healthcare Settings).

http://www.cdc.gov/hait�




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Organization findings (pg 46 of 86): EP.1: Obs. 1. During a tour of 7B three used bars of soap were found mixed together on the soap holder in a patient shower creating a potential infection control risk.

EP1, Obs 1; 7B BAR SOAP: Effective 1/2/2014 , the Dept of Psychiatry stopped ordering bar soap and replaced with individual bottle of body wash for patient use. Effective 11/2013, a hospital task force began studying alternatives to bar soap including replacement with single serving packets of liquid soap (short-term) and wall mounted soap dispensers in patient showers (long-term); product evaluation completed 1212013 and Coloplast product selected. Materials Management placed in PMM inventory 1/6/2014. Memo sent to Nurse Manager staff 1/14/2014 announcing change. Nurse Manager or designee will conduct weekly EOC rounds to assess for on-going compliance with individual bottles in shower room.

Elaine Dekker Terry Dentoni Kathy Jung Leslie Dubbin Kathy Ballou Francisco Saenz Sarah Doernberg Kathy Ballou Nela Ponferrada Sharon Kwong Jennie Farr

Organization findings (pg 46 of 86): [CONTINUED] Obs. 2. During a tour of 7B the patient clothes washer was observed to have a collection soap and other debris on the around the soap dispenser and other areas indicating that the schedule for cleaning the washing machine is not being followed.

EP1, Obs 2; 7B CLOTHES WASHER: Effective 1/4/2014, the Director of EVS clarified with EVS staff that cleaning laundry room includes wiping the exterior of machines and the interior of machine lids and added these items to the EVS cleaning checklist. Nurse Manager or designee will conduct weekly EOC rounds to assess for on-going compliance with washer/dryer cleanliness.


Observations 3 and 4. During a tour, it was noted that a stretcher located outside of 4D had a crack in the mattress. This could expose a patient to blood and body fluids. It was also noted on 5E that a drainage bag was touching the floor. This is not permitted by policy.

EP1, Obs 3 & 4; 4D MATRESS & 5E BAG: Beginning 1/13/14, the Infection Control Program Manager is meeting with representatives from each department that owns gurneys to re-educate them regarding the established formal processes for scheduling inspections and requesting repair/replacement as needed. Facility Management is designated primary responsibility for storage and replacement of new mattresses. Educated owning areas to visually inspect gurney mattresses with every cleaning and

Elaine Dekker Terry Dentoni Kathy Jung Leslie Dubbin Kathy Ballou Francisco Saenz Sarah Doernberg Kathy Ballou Nela Ponferrada




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report defects as soon as discovered. Unit/Area managers will conduct random gurney inspections on a monthly basis and each gurney will be assessed annually at a minimum for mattress integrity. Results of annual inspection will be documented on each area's gurney inventory worksheet. The Critical Care Nurse Manager or designee will conduct daily rounds to ensure proper placement of drainage bags.

Sharon Kwong Jennie Farr

Observation 5. The blinds in Outpatient Infusion Centre and on 5A were dirty. This could put medically compromised patients at risk.

EP1, Obs 5; 4C & 5A BLINDS: On 1/13/2014 the blinds in 4C Infusion Center and 5A Solarium were removed and replaced with curtains and windows cleaned.

Francisco Saenz

Organization findings (pg 46 of 86): [CONTINUED] Observation 6. During a tour of the Psychiatric Emergency Service it was noted that at least two sleeping chairs had split seams which could create an infection control risk.

EP1, Obs 6; PES CHAIRS: Effective 12/20/2014 the two sleeping chairs were temporarily covered until replacements are delivered. Effective 1/7/2014 all furniture in PES was inspected for integrity. Effective 1/10/2014 the P.O. for replacement furniture was submitted to Materials Management; delivery date is pending. Effective 1/13/2014 inspection of furniture for integrity has been added to the PES unit EOC checklist used by unit managers or designated staff when conducting unit EOC rounds. Obs. 6: Nurse Manager or designee will conduct weekly EOC rounds to assess for on-going compliance with individual bottles in shower room, washer/dryer cleanliness, and condition of PES sleeping chairs and other vinyl surfaces.


EP 2 On 4B, it was noted that a Social Worker was not wearing PPE properly. The gown was not tied at the neck, and the gown was falling from her shoulder.

EP2; 4B SW & PPE: At the time of the finding, over-the-head isolation gowns are the approved PPE, not gowns that tied/fastened at the neck. The SW was observed with a gown that fastened at the neck via Velcro tabs, not strings. Effective 1/3/2014 the SW was instructed by the Infection Control Program Manager regarding the proper PPE gowns. Infection Control (IC) Policy 3.03 Contact Isolation was reviewed and revised to clarify that gowns must be secured

Elaine Dekker Terry Dentoni Kathy Jung Leslie Dubbin Kathy Ballou Francisco Saenz Sarah Doernberg Kathy Ballou




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and tied properly at the neck and waist. Effective 1/14/2014, this revision was approved by the Infection Control Committee. Effective 1/14/2014, laminated direction signs were posted on isolation carts MOS: EP2; 4B SW & PPE: The unit Infection Control Liaisons will conduct monthly random observation audits for four consecutive months to ensure staff use the approved PPE isolation gowns. Audit results will be reported monthly to Infection Control Committee, Nursing Administration Forum (NAF), and to Accreditation, Licensing Certification Committee (ALCC). Numerator: The number of approved PPE isolation gowns observed. Denominator: 25 observations of PPE use.

Nela Ponferrada Sharon Kwong Jennie Farr

EP 1 Noted in the dialysis area due to the physical constraints within the unit, the opportunity for cross-contamination between patients was very high. In addition, there was very limited contact isolation capabilities for a C-diff patient or any other type of transmission-based precautions. During staff interviews with the Infection Control coordinator, this issue was confirmed as to cross-contamination and lack of transmission-based precautions in the dialysis unit.

CHRONIC DIALYSIS: The building where the Renal Service Outpatient Chronic Dialysis unit is located is close to one hundred years old. The Infection Control Program manager met with the Renal Service Outpatient Chronic Dialysis leadership staff to review infection control practices to prevent cross-contamination.

Elaine Dekker Kathy Jung Max Bunuan Leslie Dubbin

IC.02.02.01: EP 2, Tier 3, A, R (pg 48 of 86): The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies. * (See also EC.02.04.03, EP 4) Note: Sterilization is used for items such as implants and surgical instruments. High-level disinfection may also be used if sterilization is not possible, as is the case with flexible endoscopes.




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Footnote *: For further information regarding performing intermediate and high-level disinfection of medical equipment, devices, and supplies, refer to the website of the Centers for Disease Control and Prevention (CDC) at hilp://www.cdc.govIhicpac/DisinfectionSt erilizationfacknowledg.html (Sterilization and Disinfection in Healthcare Settings). EP 4, Tier 4, C, R, M (pg 49 of 86): The hospital implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies.

Organization findings (pg 49 of 86): EP 2 It was found that the expiration for OPA strips was dated for 109 days after opening instead of 90 days as required by the manufacturer's instruction.

OPA STRIPS: Effective 1/3/14, SPD staff were educated to the following new procedure: Effective immediately, when a new bottle of Cidex OPA Test Strips are opened, a second SPD Tech is needed to verify the expiration date. The expiration must be 90 days after the bottle is opened. Both staff members must initial the bottle once completed. Memo to staff regarding same written 1/3/14. Effective 1/3/14, education commenced for all SPD Technicians via unit meetings and was completed by 1/6/14. Nurse Manager will complete spot checks for compliance.

Ditas Hernandez

Organization findings (pg 49 of 86): [CONTINUED] EP 4 During a tour of the Primary Care Clinic unwrapped disposable speculum were found in a drawer in the exam table. Staff member present was unaware that this presents an infection control risk.

SPECULUMS: Following the ICM survey, the General Medicine Clinic, Family Health Center, Urgent Care Center leadership adopted an new policy for the hospital-based primary care clinics regarding single-use disposable speculums. All single use disposable speculums in the General Medicine Clinic, Family Health Center, Urgent Care Center are to be kept in their individual external packaging until the time of use. Speculums found outside of package or in torn or unsealed packaging will be discarded. Policy adopted, approved and implemented on 1/13/2014. MOS: SPECULUMS: The nurse manager or his/her designee will do weekly environment of care rounds for four consecutive months to assess for ongoing compliance. The nurse managers will do weekly audits of room preparation checklists to ensure documentation of compliance with the

100% Leslie Dubbin




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new policy. Numerator: all rooms in the clinic. Denominator all speculum drawers in the clinic. Audit results be reported to Infection Control Committee and to ALCC.

EP 4 Noted in a C-Section room an Intraosseous Bone Kit was found. Within the kit was a damaged package which contained an Intraosseous needle. Sterilization integrity of the package had been compromised.

BONE KIT: Effective 12/27/30, the Anesthesia Workroom Manager, Anesthesia Workroom Clinical Director, and Anesthesia OB Clinical Director completed a review of SFGH Infection Control Policy 6.08/Storage of Supplies (Clean/Sterile) "...All personnel are responsible to inspect visually any sterile package prior to use to check for time-limited shelf life label and conditions which would constitute a presumptive break in package integrity...". Effective 12/27/30, reviewed & updated Anesthesia Policy 'Monthly Expiration Checks' to include language of 'disposable inventory' Disposable inventory is already included in the monthly-performed expiration checks, but language in policy was not. Effective 12/27/13, the Anesthesia policy update was approved by Anesthesia Leadership. Effective 01/06/13, sent out universal e-mail to the Anesthesia Clinical staff (Faculty, CRNA's, Residents, Anesthesia Techs) reminding them to check integrity of packaging prior to any product use. MOS: BONE KIT: The Anesthesia Techs will conduct random observations of the intraosseous bone kits for four consecutive months to ensure package integrity. Numerator: all intraosseous bone kits with intact packaging. Denominator: all intraosseous bone kits. Audit results will be reported monthly to Infection Control

100% Leslie Dubbin Jim Marks Elaine Dekker Kyra Quon Sarah Doernberg




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Committee and to ALCC.

EP 4 Noted on an anesthesia cart that laryngoscope blades were not protected in packaging per organizational policy

LARYNGOSCOPE BLADES: Effective 12/26/13, drafted new Anesthesia P&P #31: Procedure for Testing and Storage of Laryngoscope Blade/Handle for Anesthesia Set-Up to specifically address the preparation and storage of laryngoscopes after they have been assembled for use: 1. Prepping the laryngoscope handle: With gloved hands, the peel pack for the laryngoscope handle is opened, and the battery is inserted. The laryngoscope handle then remains in the opened peel pack. 2. Attaching/testing the laryngoscope blade: With gloved hands, the peel pack for the laryngoscope blade is opened, and the attachment end of the blade is exposed to attach to the handle for prep/testing. The laryngoscope blade remains covered with the peel pack, and is only uncovered when it's ready for use. 3. The assembled (and covered in peel packs) laryngoscope is then placed inside a plastic bag, and placed in the airway tray. The airway tray is covered until ready for use. 4. The prepped & covered laryngoscope has a designated 24 hr expiration, after which it is removed from the airway tray, for reprocessing, should it not have been used. If the laryngoscope is removed from its coverings, or is outside of the airway tray, it is also removed for reprocessing. Effective 01/05/14, new policy reviewed and approved by Anesthesia leadership. Effective the week of 1/6/14, Anesthesia clinical staff were in serviced regarding the new policy.

100% Leslie Dubbin Jim Marks Elaine Dekker Kyra Quon Sarah Doernberg




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MOS: LARYNGOSCOPE BLADES: The Anesthesia Workroom Manager will conduct random weekly observations for four consecutive months of the Anesthesia Technicians as they replenish/stock laryngoscope handles and blades between surgery cases to ensure compliance with the new policy & procedures. Numerator: all laryngoscope blades properly protected. Denominator: all anesthesia carts. Audit results will be reported monthly to Infection Control Committee, to the Anesthesia Leadership Committee, and to ALCC.

LD 03.03.01, EP 4, Tier 3, A (pg 4 of 86): Leaders provide the resources needed to support the safety and quality of care, treatment, and services.

Organization Findings (pg 4 of 86): EP 4 During the Infection Control System Tracer it was determined that the current staffing of the Infection Control Department does not meet the need for thorough surveillance and thorough follow up of infection control issues throughout the organization. There are presently two vacancies in the Infection Control Department which leaves only two Infection Control Practitioners to provide surveillance activities, assure compliance and implementation of the infection control plan. (There were numerous observations under IC standards.) It was also noted that TB is identified as Number 3 on the Infection Control Risk Assessment. The limited staffing impedes follow-up process for staff exposure to TB. Given the acuity and complexity of this organization this staffing shortage creates a risk for continued and additional infection control risk points.

The San Francisco General Hospital (SFGH) position for an Infection Control Healthcare Analyst was posted and candidates were interviewed in November 2013. Due to an unqualified applicant pool, a candidate was not selected from the applicants interviewed. The SFGH position for Infection Control Healthcare Analyst will be reposted to search for qualified individuals to fill this vacant position. SFGH Leadership has requested approval to fill this position on a provisional requisition, which enables us to hire in a more timely manner. Staff training to the infection control program will be provided after hire using SFGH-adapted Association for Practioners in Infection Control and Epidemiology (APIC) professional development model. Anticipate posting for hire by February 1, 2014 The University of California San Francisco (UCSF) Infection Control Practitioner position will be converted to a SFGH RN position which will allow for expedited placement through reassignment of a current SFGH RN. Staff training to the infection control program will be provided after hire using

Iman Nazeeri-Simmons Troy Williams Lisa Winston Sarah Doernberg Elaine Dekker Terry Dentoni




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SFGH-adapted APIC professional development model. Anticipate posting for reassignment by January 20, 2014. Infection control currently has a part-time UCSF RN who works 20 hours per week conducting our VAP and CAUTI surveillance chart reviews as well as supporting our overall IC program. This position was not clearly described as a formal member of the Infection Control Department during the ICM survey process.

LD 04.01.05, EP4, Tier 4, A, R (pg 8 of 86): Staff are held accountable for their responsibilities.

Organization Findings (pg 8 of 86): EP 4 It was found that the time documented of providing discharge instructions was 7.15 am and 12noon. On review of medical record, it was found that procedure ended at 11.36 am and patient was moved into PACU at 11.55 am. Around this time, mental status on Modified Aldrete score was documented as zero.

DISCHARGE INSTRUCTIONS: The PACU Nurse Manager met with the staff to review the findings. The PACU Nurse Manager is revising the Discharge Instructions Form given to patients prior to going home after surgery to include the following: • The date and time the discharge instructions were given to the patient by the RN. • The date and time the provider wrote the discharge order. During the 1/14/14 Medical Executive Committee (MEC) meeting, the Chief Medical Officer reviewed the findings and clarified the requirement that discharge orders are written at the time of discharge. The revised forms will be distributed to the Surgicenter Department and incorporated into the Surgicenter packet for all Come and Go patients once the forms are available. The Surgicenter nurses and the PACU nurse will be in serviced on the use of the revised new forms. All of the old forms will be discontinued and taken out of circulation. The PACU Nurse Manager or designee will audit the discharge

Jim Marks Robin Stackhouse Iman Nazeeri-Simmons




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documentation of 100% of the patients discharged to home from the PACU until 90% compliance with requirement that discharge orders are dated/signed post-procedure is met.

EP 4 While touring 5E, it was noted that the medication refrigerator had an external thermometer. Staff were questioned whether the temperatures were monitored by the facilities staff and were told yes. It was later identified that the work has been in progress for two years (using a contractor), and that there have been calibration issues. Facilities staff have not been monitoring the temperatures. This demonstrated ineffective communication between facilities staff and nursing staff.

FRIDGE TEMPS: The hospital has been piloting an electronic temperature monitoring system for the medication refrigerators; however, it is not yet operational. The system the hospital uses is a stand-alone external electronic thermometer (white box) mounted on the medication refrigerators which continuously records the refrigerator temps. The 5E nursing staff manually monitor the local external thermometer (white box) on the medication refrigerators and manually record the medication refrigerator temps once each shift on a paper log. The nurses report any out-of-range temperature findings to Pharmacy; Facilities engineers are then notified to assess, repair or replace equipment indicated. The Director of Facilities and the Chief Nursing Officer will issue a memo to all nursing personnel to clarify the medication refrigerator temperature monitoring process.

Kathy Jung Max Bunuan Greg Chase Kathy Ballou Jennie Farr

LD 04.01.07, EP 1, Tier 4, A, R (pg. 9 of 86): Leaders review and approve policies and procedures that guide and support patient care, treatment, and services. (See also NR.02.03.01, EP 1; RI.01.07.01,EP 1)

Organization Findings (pg 9 of 86): EP 1 It was found that there was no fall risk assessments or safety check for falls done in GI procedure area. Also there were no policies or procedures for fall prevention in these areas

Following the ICM survey, the Outpatient leaders, in collaboration with the Patient Safety Falls Prevention Task Force members, met and developed the "SFGH Fall Risk Screen Outpatient Areas" tool as of January 10, 2014. The tool defines environmental factors and age specific fall risk interventions for outpatient and outpatient/procedural areas.

The Outpatient fall risk screening and procedural area interventions are being incorporated into the SFGH Admin

Terry Dentoni Leslie Dubbin Tom Holton Janet Kosewic




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Policy 6.07/Falls Policy.

The Outpatient and Outpatient/Procedural area staff will be educated about fall risk screening and procedural area interventions by February 28, 2014.

The Patient Safety Falls Prevention Task Force will be responsible to:

- Monitor, submit and benchmark outpatient falls according to NDNQI guidelines quarterly.

- Provide outpatient unit-specific fall rate reports annually

The Outpatient leaders will incorporate a proactive assessment of environmental factors that may pose a falls risk when conducting their unit biannual EOC rounds.

The changes made to Admin Policy 6.07/Falls Policy have been incorporated into new employee hospital orientation and annual updates.

Based on over 500 outpatient clinic visits and procedures per month, the Patient Safety Falls Prevention Task Force will monitor 70 visits/procedures for the use of the outpatient fall risk screen and /outpatient procedural area interventions for four continuous months.

Denominator= total number of provider visits or procedures

Numerator= total number of correctly completed screenings or procedural area interventions implemented

Audit results will be reported monthly to the Nursing




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Quality Forum (NQF) and quarterly to Quality Council.

LD.04.03.07 (ADD-ON pg to exit summary): EP 1, Tier 4, A, R: Variances in staff, setting, or payment source do not affect outcomes of care, treatment or services in a negative way. EP 2, Tier 4, A, R: Care, treatment, and services are consistent with the hospital’s mission, vision, and goals.

Organization findings: ADD-ON It was found that there was no RASS score documentation while the patient continued to be on propofol drip at 70 micrograms/kg/minute in the cardiac cath area for the procedure. Prior to being in cardiac cath area, patient was monitored for a sedation RASS goal of -2. While In the cardiac cath area, documentation was for level of consciousness from 0 to 2. ICU and cardiac cath are on different EMR. The hospital has at least 7 different Electronic Medical Record Systems with interfaces not communicating. This could compromise quality of care-and patient safety.

The Nursing Director has standardized RASS score documentation in the ICU & Cardiac Cath Lab.

Jensen Wong Terry Dentoni Jennie Farr Leslie Dubbin Jeff Schmidt Winona Mindolovich

LD 04.03.09, EP 5, Tier 4, A, R (pg 13 of 86): Leaders review and approve policies and procedures that guide and support patient care, treatment, and services. (See also NR.02.03.01, EP 1; RI.01.07.01,EP 1)

Organization Findings (pg 15 of 86): EP 5 There was no documentation of quality metrics defined in the contract of services given by the TB clinic from Dept of Public Health to the org There was no documentation of quality metrics for Interpretation Services. Apparently, the company is collecting data related to timeliness, but this data has not been shared with this organization.

Following the ICM survey, effective December 31, 2013, all patient care contracts were reviewed to assess compliance with establishing measurable quality metrics. As of 12/31/13, 35/52 patient care contracts included current quality metrics. The TB Clinic is a City & County of San Francisco (CCSF) Department of Public Health (DPH) clinic located on the SFGH campus but is not on the facility license nor is it a

Iman Nazeeri-Simmons Anson Moon Jenny Chacon Sue Schwartz Leslie Dubbin Troy Williams Maggie Rykowski




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contracted service with SFGH. Performance measure data for Interpreter Services contracts will be made available to the organization by 1/31/14. It is the responsibility of each Associate Administrator with oversight of a patient care contract to monitor the effectiveness of the contract including compliance with the quality metrics and having available data on request. By 2/28/14, all patient care contracts will have documented quality metrics, which are included in each department's Performance Improvement (PI) Plan. Contract quality metrics are reported to the Quality Council as part of each department's annual PI report. These reports are submitted for approval to the Governing Body Joint Conference Committee as part of the monthly Quality Council minutes. 90% of patient care contracts will include measurable quality metrics and be included in the departmental PI plan for 2014. Each month, all departments reporting to the Quality Council will include contract quality metric data in the annual PI report to this hospital committee.

LS.02.01.20, EP 13, Tier 4, C, R (pg 31 of 86): Exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts, furniture), construction material, and snow and ice, (For full text and any exceptions, refer to NFPA 101-2000:7.1.10.1)

Organization Findings (pg 32 of 86): EP 13 Procedure table with iv pole found stored in hall way by the door near 1x51

The Chief Engineer met with Radiology Supervisors 12/13/13 to remind them of the requirement that exits are clear of obstructions and clutter and removed the

Max Bunuan Rich Elliot Greg Chase




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Lead shield and procedure table found stored in hallway near Stair 9 Items were stored in exit hails on several units. Some units had signage that indicated where Computers on Wheels were to be stored in the exit hallways.

storage/clutter from the Radiology corridor near 1X51 and stair 9. Patient Safety rounds and EOC rounds are conducted on the units; exits are monitored for obstructions and clutter and any non-compliance corrected in real time.

Lann Wilder Terry Dentoni Tom Holton

LS.02.01.30 EP 6, Tier 4, C, R (pg. 33 of 86): Existing corridor partitions are fire rated for 1/2 hour, are continuous from the floor slab to the floor or roof slab above, extend through any concealed spaces (such as those above suspended ceilings and interstitial spaces), are properly sealed, and are constructed to limit the transfer of smoke. Note: In smoke compartments protected throughout with an approved supervised sprinkler system, corridor partitions are allowed to terminate at the ceiling if the ceiling is constructed to limit the passage of smoke. The passage of smoke can be limited by an exposed, suspended-grid acoustical tile ceiling. The following ceiling features also limit the passage of smoke: sprinkler piping and sprinklers that penetrate the ceiling; ducted heating, ventilating, and air-conditioning (HVAC) supply and return-air diffusers; speakers; and recessed lighting fixtures (For full text and any exceptions, refer to NFPA 101-2000: 19.3.6.2.1 and 19.3.6.2.2) EP 11, Tier 4, C (pg 35 of 86): Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are hinged so that they swing. The gap between meeting edges of door pairs is no wider than 1/8 inch and undercuts are no larger than 1 inch. Roller latches are not acceptable. Note: For existing doors, it is acceptable to use a device that keeps the door closed when a force of 5 foot-pounds are applied to the edge of the door. (For full text and any exceptions, refer to NFPA 101-2000: 18119.3.6.3.2, 18/19.3.6.3.1, and 7.2.1.4.1).

Organization Findings (pg 36 of 86): EP 6 Escutcheons in the cardiac cath lab was found not firmly fixed to the ceiling and had gaps for smoke to escape in the event of a fire.

The Facilities engineer adjusted the escutcheon on the sprinkler head inside the Cath Lab, Ward 5G; work order 604818 completed 12/23/2013. Compliance sustained via Environment of Care (EOC) tours.

Kathy Jung Max Bunuan Greg Chase

EP 11 It was noted that the positive latching hardware on a corridor door outside the cafeteria was taped shut. This rendered the hardware inoperable. It was also noted that two separate corridor doors were not closed properly which prevented the positive latching hardware from working.

The Facilities engineer removed the tape from the door latch; work order 604980 completed 12/13/2013. Compliance sustained via EOC tours. The Facilities engineer repaired the doors near Administration and posted a sign indicating which door to push open so that the door closes and latches properly; work order 604930 completed 12/11/2013. Compliance

Kathy Jung Max Bunuan Greg Chase




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sustained via EOC tours.

LS.02.01.35 EP 5, Tier 4, C (pg 36 of 86): Sprinkler heads are not damaged and are free from corrosion, foreign materials, and paint. (For full text and any exceptions, refer to NFPA 25-1998:2-2.1.1) Organization Findings (pg 37 of 86): EP 5 Observation 1 Fire Sprinkler in hallway outside Room 5 on Telemetry floor found with thick layer of dust

Facilities engineer cleaned the fire sprinkler heads outside Tele Rm 5 & Zone 2 MRI on 12/13/13 per work order 604984. Currently, Facilities engineers are responsible for ensuring sprinkler heads in the main hospital corridors are clean; the Director of Facilities is adding twice a year cleaning and inspection of the sprinkler heads in the main hospital corridor to the preventative maintenance (PM) schedule. The Director of Facilities or designee will conduct random observation audits to ensure compliance. Currently, the EVS staff are responsible for ensuring sprinkler heads in the main hospital patient units are cleaned. EVS Policy D8/Dusting of Water Sprinkler Heads in All Patient Units requires the sprinkler heads to be dusted twice a year. The Director of EVS will monitor the completed work reports and conduct random observation checks to ensure compliance with the policy.

Kathy Jung Francisco Saenz Lann Wilder

EP 5 Observation 2 Fire sprinkler in zone 2 MRI was found with a thick layer of dust

Facilities engineer cleaned the fire sprinkler heads outside Tele Rm 5 & Zone 2 MRI on 12/13/13 per work order 604984. Currently, Facilities engineers are responsible for ensuring sprinkler heads in the main hospital corridors are clean; the Director of Facilities is adding twice a year cleaning and inspection of the sprinkler heads in the main hospital corridor to the preventative maintenance (PM) schedule.

Kathy Jung Francisco Saenz Lann Wilder




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The Director of Facilities or designee will conduct random observation audits to ensure compliance. Currently, the EVS staff are responsible for ensuring sprinkler heads in the main hospital patient units are cleaned. EVS Policy D8/Dusting of Water Sprinkler Heads in All Patient Units requires the sprinkler heads to be dusted twice a year. The Director of EVS will monitor the completed work reports and conduct random observation checks to ensure compliance with the policy.

MM.03.01.01 EP 5, Tier 4, C, R, M (pg. 21 of 86): The hospital implements its policy addressing the control of medication between receipt by an individual health care provider and its administration. EP 6, Tier 4, A: (pg. 22 of 86): The hospital prevents unauthorized individuals from obtaining medications in accordance with its policy and law and regulation.

Organization Findings (pg 22 of 86): EP 5 It was found that discrepancy in the wastage amount of Versed in the cardiac cath area on March 18 2013 was not brought to the immediate attention of the pharmacist as required by Nursing Dept Policy 17.12

Following the ICM survey, Nursing Policy 17.12/Controlled Substances was revised in December 2013 to clarify that the Department of Pharmacy is notified about controlled substance discrepancies only when they cannot be resolved at the unit level. MOS: 100% of unresolved controlled substance discrepancies reported from the Cardiac Cath Lab to the Pharmacy will be tracked and reported monthly for four consecutive months to Pharmacy & Therapeutics (P&T) Committee, to the Medication Error Reduction Plan (MERP) Committee, and to Joint Nursing Pharmacy Committee (JNP).

100% Dave Woods Elena Tinloy Julie Russell Jennie Farr

EP 6 Medications brought in by patients to the hospital if not used or cannot be returned home are held in cashier's office. In this place the surveyor found several medications including methadone in unlocked cabinets. Also medical

MEDICATION STORAGE: During admission, patients are encouraged to send all medications brought from home back to their residence. Pharmacy and Nursing leadership are revising Admin Policy 16.02 Patient Clothing and

Dave Woods Elena Tinloy Julie Russell Jennie Farr




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marijuana was found in unlocked cabinet being stored in cashier's office as SFGH providing custodian services to law enforcement.

Valuables, Admin Policy 16.3 Pharmaceutical Service: Guidelines for Storage & Delivery of Meds, and Nursing Policy 17.05/Administration of Medications to add language that the Department of Pharmacy will be responsible for the storage of medications brought by patients from home when the patients cannot send the medications back. The Pharmacy will store the medications until the patient is discharged. Pharmacy and Nursing leadership will in-service their staffs about this change and the revised policies via staff meetings and memos; anticipate completion by February 28, 2014. The Director of Pharmacy will review the Pharmacy Log of Patient's Own Medication on a monthly basis and will report monitoring results quarterly to the Joint Nursing Pharmacy Committee (JNP), to the Medication Error Reduction Plan (MERP), and to the Pharmacy and Therapeutics Committee (P&T). The Director of Pharmacy will compare all of the Receipts for Patient's Valuables against the Pharmacy Log sheet for Patient's Own Medications to ensure compliance with the revised policies. Results will be presented to JNP, MERP and P&T committees.

EP 6 Noted that the satellite pharmacy was not secured. A pharmacist was within the physical space. However, the door to the pharmacy was propped open with a cart. Trays of medications including narcotics were readily available.

SATELLITE PHARMACY: The door to the OR satellite will be closed; a sign will be placed on the indicating when a pharmacist is present. Medications located on the cart have been relocated effective 12/17/13. The Pharmacy Supervisor will conduct random observation audits of the OR satellite pharmacy door to ensure compliance with the requirement that the door be closed.

Dave Woods Elena Tinloy Julie Russell Jennie Farr




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MM.05.01.11, EP 2, Tier 4, C, M (pg 23 of 86): The hospital dispenses medications and maintains records in accordance with law and regulation, licensure, and professional standards of practice. Note: Dispensing practices and recordkeeping include anti-diversion

Organization Findings (pg. 24 of 86): EP2 While touring two ICUs (5E and 5R), it was noted that in each unit there was a pill crusher with medication residue. This could result in patients receiving residue of medications to which they had allergies.

Pharmacy and Nursing leadership will educate nursing staff via read-and-sign memo that pill crushers and splitters are to be wiped free of visible medication remnants before use and after each medication is crushed. The memo includes information on correct procedure for both manual and automatic pill crushers. The Director of Pharmacy Services and the Nursing Director for Medication Management have submitted a purchase order to obtain automated pill crushers for unit medication rooms (e.g. "Silent Knight" pill crusher). The automated pill crusher requires that the nurse utilize an individual sleeve between each use of the device. Pharmacy leadership is revising the inpatient nursing unit monthly inspection report completed by pharmacists to include the inspection of the pill crushers/splitters for cleanliness. Nursing leadership is incorporating inspection of the pill crushers/splitters via a checklist added to the medication refrigerator temperature monitoring log which is completed twice daily by the charge RN or designee. Checklists will be reviewed for completion by the Nurse Manager, and forwarded to the Medication Management Nursing Director. Pill crusher cleanliness inspection results will be reported monthly for four consecutive months to the Joint Nursing Pharmacy Committee (JNP), to Nursing Administration Forum (NAF), and to Medication Error Reduction Plan (MERP) Committee.

90% Dave Woods Elena Tinloy Julie Russell Jennie Farr Kathy Ballou Terry Dentoni




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MOS: The nurse managers/clinical pharmacists will conduct ten random direct observation audits of the pill crushers/splitters monthly for four consecutive months to ensure that the pill crushers/splitters are clean and free of visible medication residue. Numerator: all pill crushers/splitters observed to be clean and free from visible medication residue. Denominator: all pill crushers/splitters in the unit medication rooms

Observation 2 During a tour of the PES it was noted that the pill splitter had some medication

Pharmacy and Nursing leadership will educate nursing staff via read-and-sign memo that pill crushers and splitters are to be wiped free of visible medication remnants before use and after each medication is crushed. The memo includes information on correct procedure for both manual and automatic pill crushers. The Director of Pharmacy Services and the Nursing Director for Medication Management have submitted a purchase order to obtain automated pill crushers for unit medication rooms (e.g., "Silent Knight" pill crusher). The automated pill crusher requires that the nurse utilize an individual sleeve between each use of the device. Pharmacy leadership is revising the inpatient nursing unit monthly inspection report completed by pharmacists to include the inspection of the pill crushers/splitters for cleanliness. Nursing leadership is incorporating inspection of the pill crushers/splitters via a checklist added to the medication refrigerator temperature monitoring log which is completed

90% Dave Woods Elena Tinloy Julie Russell Jennie Farr Kathy Ballou Terry Dentoni




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twice daily by the charge RN or designee. Checklists will be reviewed for completion by the Nurse Manager, and forwarded to the Medication Management Nursing Director. Pill crusher cleanliness inspection results will be reported monthly for four consecutive months to the Joint Nursing Pharmacy Committee (JNP), to Nursing Administration Forum (NAF), and to Medication Error Reduction Plan (MERP) Committee. MOS: The nurse managers/clinical pharmacists will conduct ten random direct observation audits of the pill crushers/splitters monthly for four consecutive months to ensure that the pill crushers/splitters are clean and free of visible medication residue. Numerator: all pill crushers/splitters observed to be clean and free from visible medication residue. Denominator: all pill crushers/splitters in the unit medication rooms

MS. 03.01.01, EP 16, Tier 4, A, R (pg. 19 of 86): For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff determines the qualifications of the radiology staff who use equipment and administer procedures.

Organization Findings (pg.19 of 86): EP 16 There was no documentation that the medical staff determines the qualifications of the radiology staff who use equipment and administer procedures.

Following the ICM survey, the Chief of Service for Radiology reviewed the job descriptions and qualifications for Radiology Technologists DT 1, DT II, DT III, DT IV, for Radiology Supervisor, for Director of Radiology. The Chief of Service for Radiology will present the job descriptions and qualifications of the Radiology Technologists DT 1, DT II, DT III, DT IV, the Radiology

Dan Schwager Mark Wilson Alan Gelb Todd May Shannon Thyne




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Supervisor, and the Director of Radiology at the February2014 Medical Executive Committee meeting for formal review and approval. Moving forward, the Chief of Service for Radiology will include the job descriptions, qualifications, and any changes as part of the annual approval process for the Radiology Clinical Service rules and regulations.

NPSG 15.01.01: Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders In general hospitals. EP 1, Tier 3, C, D, M, R (ADD-ON pg to exit summary): Conduct a risk assessment that identifies specific patient characteristic and environmental features that may increase or decrease risk for suicide. EP 2, Tier 3, C, M, R (ADD-ON pg to exit summary): Address the patient’s immediate safety needs and most appropriate setting for treatment. EP 3, Tier 3, C, M, R (ADD-ON pg to exit summary): When a patient at risk for suicide leave the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.

Organization Findings: ADD-ON EP1 During a review of a patient record on the psychiatric service it was noted that there was a suicide risk screen, but note full suicide risk assessment.

Terry Dentoni Janet Kosewic Leslie Dubbin Tom Holton Kathy Ballou

EP 1 During a review of a second patient record on the psychiatric service it was noted that there was a suicide risk screen, but not a full suicide risk assessment.

Terry Dentoni Janet Kosewic Leslie Dubbin Tom Holton Kathy Ballou

Organization Findings: ADD-ON [CONTINUED] EP 1 During a review of a third patient record on the psychiatric service it was noted that there was a suicide risk

Terry Dentoni Janet Kosewic Leslie Dubbin




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screen, but not a full suicide risk assessment. It was determined the policy only requires a brief suicide risk screen for psychiatric patients instead of a thorough risk assessment.

Tom Holton Kathy Ballou

PC.01.02.01: EP 1, Tier 4, A, D, R (pg. 73 of 86): The hospital defines, in writing, the scope and content of screening, assessment, and reassessment information it collects. (See also RC.02.01.01, EP 2). Note 1: In defining the scope and content of the information it collects, the organization may want to consider information that it can obtain, with the patient's consent, from the patient's family and the patient's other care providers, as well as information conveyed on any medical jewelry. Note 2: Assessment and reassessment information includes the patient's perception of the effectiveness of, and any side effects related to, his or her medication(s). EP 23, Tier 3, C, R, M (pg. 73 of 86): During patient assessments and reassessments, the hospital gathers the data and information it requires. (See also PC.01.01.01, EP 24) Organization findings (pg 74 of 86): EP 1 The Policy "Screening, Assessment and Management of the Potentially Suicidal Patient in a Non-Psychiatric Setting" was reviewed. The following was noted: there was not a clear delineation of responsibility for screening or risk assessments and there was not a clear plan of action to be taken if patient was determined to be at risk. It was further noted that the policy stated that a suicide risk screen was done in Ambulatory Clinics. However, a depression assessment screen is done, not a suicide risk screen.

EP1 (Suicide policy): The SFGH campus-based clinic leadership met, reviewed and agreed to implement evidence based outpatient suicide risk screening and assessment and it will be integrated into the SFGH Policy 1.19 "Screening Assessment & Management of the Potentially Suicidal Patient in a Non-Psychiatric Setting'. Per policy, the specialty clinics are excluded because their patients have been screened in the clinics, ED or inpatient setting prior to referral to specialty clinic. The policy redefined who will do the suicide risk screening and assessing in the outpatient, ED and inpatient settings. The process for implementing the suicide risk screening was tested in 1M clinic on a paper form. The paper form will be used to document suicide risk screening until integrated into the outpatient electronic documentation system (eCW). Effective 12/31/13, provider feedback sought and obtained. Effective 1/13/14, the outpatient interdisciplinary team reviewed and revised 1.19 to include Outpatient suicide risk screening and assessment processes. Effective 1/13/14, MEA training on the use of the suicide risk screening questions was implemented, feedback from

Terry Dentoni Tom Holton Janet Kosewic Nela Ponferrada Leslie Dubbin Jennie Farr Kathy Ballou




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the test of the screening tool in 1M clinic was used to revise and retest, spread to the other outpatient clinics was initiated. Once fully tested, will integrate the screening and assessment questions into the electronic record for all clinics; until the clinics are using ECW, they will use the paper screening tool. The outpatient clinic Nurse Manager or designee(s) will audit the medical records of 100% of the clinic/unit's patient visits for completion of a suicide risk screen. Numerator' All clinic visit medical records with completed suicide risk screen. Denominator All clinic visits. The audit results will be reported to Nursing Quality Forum (NQF), to Ambulatory Care Committee, and to Accreditation, Licensing, Certification Committee (ALCC).

EP 23. During a review of an initial nursing assessment on the psychiatric service it was noted that aspects of the nursing assessment could not be completed due to the patient’s condition. There was no evidence of an attempt to complete the assessment at a later date. During a review of the suicide risk assessment on the same patient it was noted that aspects of the assessment were missing, there was no evidence of an attempt to complete at a later date.

EP23 M (reassessment of pt once able to participate in screening): Nursing leadership is revising Nursing Policy 11.2/Documentation of the Nursing Process to clarify that the RN reviews and updates incomplete or unable to assess responses in the nursing admission database (NAD). When the nurse completing the nursing admission database (NAD) marks a field "patient unable to participate" or "unable to assess", this is noted on the Nursing Kardex. A new line is being added to the Kardex which reads "NAD. completed/unable". Staff will circle either "completed" or "unable". At shift handoff, the oncoming and off going RNs will review whether or not the NAD is completed. If the NAD is incomplete, the oncoming RN will assess the patient and attempt to complete any of the questions that have not been completed until the patient is either able to participate and completes the questions or the patient leaves the facility.





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EP 23 While reviewing the record of a 4B patient on CIWA protocol, it was noted that on two occasions a sedation score was not documented following medication administration, as ordered.

EP23 M (CIWA score not documented following med administration): The 4B Nurse Manager re-educated 4B staff about the requirement in the Severe CIWA protocol to document the sedation score 30 minutes after IV medication administration. Even though Med/Surg units do not administer the Severe CIWA protocol, they will have a review about documenting the sedation scale per the moderate CIWA protocol during the MedSurg education sessions beginning 1/15/14. The Severe CIWA protocol is low volume. Staff will review 100% of the records of patients on the Severe CIWA protocol for appropriate documentation of the sedation scale per the Severe CIWA protocol. MOS: P23M (reassessment of pt once able to participate in screening): The CNS or designee(s) will audit the medical records of 10 patients per unit per month for four consecutive months to ensure that the NADs are complete The sample size will be 70 audits per month from the admitting nursing units. Numerator: All completed Nursing Admission Databases (including NADS where CNS has verified patient still unable to participate). Denominator: All Nursing Admission Databases. The audit results will be reported to Nursing Quality Forum(NQF) and to Accreditation, Licensing, Certification Committee (ALCC). EP23 M (CIWA score not documented following med administration):The 4B CNS or designee(s) will audit the medical records of 100% of 4B patients ordered for Severe





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CIWA Protocol for four consecutive months for evidence of compliance with requirement to document the sedation scale 30 minutes after the medication is given. Numerator: All 4B patients with orders for Severe CIWA Protocol patients medical records with documentation of sedation scale 30 minutes after the medication is given. Denominator: All medical records of 4B patients with Severe CIWA Protocol orders. Audit results will be reported to Nursing Quality Forum(NQF) and to Accreditation, Licensing, Certification Committee (ALCC).

PC.01.02.03, EP 4, Tier 4, C, R, M (Pg 75 of 86): The patient receives a medical history and physical examination no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. (See also MS.03.01.01, EP 6; RC.02.01.03, EP 3).

Organization findings (pg 76 of 86): EP 4 It was found that the patient did not receive a medical history and physical examination no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. There were 3 of these observations.

EP4 M: The Chief of Anesthesia Service is revising the Anesthesia Service Rules and Regs Pre-operative Anesthesia Evaluation section to add language clarifying the requirement that patients receive a medical history and physical examination no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. MOS: EP4 M: The Dept of Anesthesia will audit 70 medical records per month for four consecutive months of patients who received anesthesia services to verify compliance with the requirement that the patient received a medical history and physical examination no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia

Todd May Shannon Thyne




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services. Numerator: the number of patients who received anesthesia services and received a medical history and physical examination within the required time frame. Denominator: the number of patients who received anesthesia services.

PC.01.03.01, EP 1, Tier 3, C, R, M (pg 76 of 86): The hospital plans the patient's care, treatment, and services based on needs identified by the patient's assessment, reassessment, and results of diagnostic testing. (See also RC.02.01.01, EP 2).

Organization findings (pg 76 of 86): EP 1 While reviewing a care plan on 4th floor, it was noted that although the patient was a paraplegic and had a Stage 4 pressure ulcer, that neither of these needs were identified on the care plan.

EP1 M (paraplegia and PU not identified on care plan) and EP 1 M (knowledge deficit r/t new medications and post op infection prevention not identified on the care plan): The Chief Nursing Officer and/or designees will audit care plans to ensure care plans are individualized; they will resolve any issues identified in real time with coaching and feedback to staff. Utilizing the data collected through the nursing audits, nursing leadership will review the data for trends and develop additional measures using the Plan-Do-Study-Act (PDSA) methodology to improve nursing practice to ensure care plans are individualized. MOS: EP1 M. The Chief Nursing Officer and/or designees will audit care plans of 10 patients in all the acute care clinical settings (e g., Med Surg, Critical Care, acute Psychiatry, Pediatrics, Birth Center, Nursery) per month for four consecutive months to ensure that the care plans are individualized The sample size will be 70 audits per month from the nursing units.

Terry Dentoni Kathy Ballou Nela Ponferrada Jennie Farr Leslie Dubbin Mary Jo Webb




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Numerator: All individualized nursing care plans Denominator: All nursing care plans The audit results will be reported to Nursing Quality Forum(NQF) and to Accreditation, Licensing. Certification Committee (ALCC).

Organization Findings: [CONTINUED] EP 1 Noted that the plan of care did not have a goal related to 'knowledge deficit associated with new medications initiated during the present hospitalization. Interventions had been established related to patient education related to the new medications. The education was not individualized to the identification of the specific medications. In addition, a problem/need was not included within the written plan of care relative to infection control/prevention nursing care related to the postoperative patient care. The patient had undergone an exploratory laparotomy, splenectomy, colectomy, and colostomy procedures.

EP1 M (paraplegia and PU not identified on care plan) and EP 1 M (knowledge deficit r/t new medications and post op infection prevention not identified on the care plan): The Chief Nursing Officer and/or designees will audit care plans to ensure care plans are individualized; they will resolve any issues identified in real time with coaching and feedback to staff. Utilizing the data collected through the nursing audits, nursing leadership will review the data for trends and develop additional measures using the Plan-Do-Study-Act (PDSA) methodology to improve nursing practice to ensure care plans are individualized. MOS: EP1 M. The Chief Nursing Officer and/or designees will audit care plans of 10 patients in all the acute care clinical settings (e g., Med Surg, Critical Care, acute Psychiatry, Pediatrics, Birth Center, Nursery) per month for four consecutive months to ensure that the care plans are individualized The sample size will be 70 audits per month from the nursing units. Numerator: All individualized nursing care plans Denominator: All nursing care plans

Terry Dentoni Kathy Ballou Nela Ponferrada Jennie Farr Leslie Dubbin Mary Jo Webb




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The audit results will be reported to Nursing Quality Forum(NQF) and to Accreditation, Licensing. Certification Committee (ALCC).

PC.02.01.03, EP 1, Tier 3, A, R (pg 79 of 86): For hospitals that use Joint Commission accreditation for deemed status purposes: Prior to providing care, treatment, and services, the hospital obtains or renews orders (verbal or written) from a licensed independent practitioner or other practitioner in accordance with professional standards of practice; Law and regulation; hospital policies; and medical staff bylaws, rules, and regulations. *Footnote*: For law and regulation guidance pertaining to those responsible for the care of the patient, refer to 42 CFR 482.12(c).

Organization findings (pg 79 of 86): EP 1 A patient on 5A was placed on suicide precautions by nursing staff. There was no physician order for these precautions, which restrict patient rights.

EP1 (no MD order for suicide precautions and no written order for medication given)- The Chief Nursing Officer and/or designees conducted an audit of all current in-patients to ensure physician orders are completed and transcribed to the Kardex, they resolved any issues identified in real time with coaching and feedback to staff - completed 1/10/14. Utilizing the data collected through the nursing audits, hospital leadership will review the data for trends and develop performance improvement (PI) projects focusing on ensuring that physician orders are completed and transcribed to the Kardex.

Terry Dentoni Nela Ponferrada Kathy Ballou Leslie Dubbin Jennie Farr Mary Jo Webb Todd May Tom Holton Janet Kosewic

Organization Findings: [CONTINUED] EP 1 A patient in the Primary Care Clinic received a dose of one Glucose Tab without a written order.

EP1 (no MD order for suicide precautions and no written order for medication given)- The Chief Nursing Officer and/or designees conducted an audit of all current in-patients to ensure physician orders are completed and transcribed to the Kardex, they resolved any issues identified in real time with coaching and feedback to staff - completed 1/10/14. Utilizing the data collected through the nursing audits, hospital leadership will review the data for trends and develop performance improvement (PI) projects focusing on

Terry Dentoni Nela Ponferrada Kathy Ballou Leslie Dubbin Jennie Farr Mary Jo Webb Todd May




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ensuring that physician orders are completed and transcribed to the Kardex.

PC.02.02.01, EP 2, Tier 3, C, R, M (pg 82 of 86): The hospital's process for hand-off communication provides, for the opportunity for discussion between the giver and receiver of patient information. Note: Such information may include the patient's condition, care, treatment, medications, services, and any recent or anticipated changes to any of these.

Organization findings pg 82 of 86): EP 2 Hospital policy requires that a transfer form be faxed from the transferring unit to the receiving unit when a patient is transferred. While reviewing a record on 5R, it was noted that the faxed form was not available in the medical record.

EP2 M (faxed transfer form not in medical record). The Chief Nursing Officer notified all nursing staff via memo that effective the date of the memo, 12/30/13, verbal reports are mandatory any time a patient's care is transferred from one area to another including procedural and/or surgical areas Appropriate unit specific transfer forms are to be completed and sent to the receiving unit; the sending unit RN will document the handoff and the name of the receiving nurse to whom the verbal report was given. MOS: EP2 M. The Nurse Manager or designee of patient clinical settings will conduct ten weekly random concurrent observations for four consecutive months of hand-offs when a patient's care is transferred from one area to another, including procedural and/or surgical areas, to ensure verbal reports are done. Numerator: number of verbal reports at time of patient hand-off. Denominator: all patient handoffs.

Tom Holton Janet Kosewic

PC.02.02.03, EP 11, Tier 3, C (pg 83 of 86): The hospital stores food and nutrition products, including those brought in by patients or their families, using proper sanitation, temperature, light, moisture, ventilation, and security.

Organization findings (pg 83 of 86): EP 11 While touring the walk in refrigerators in the kitchen,

EP11: The Director or Food and Nutrition Service (FNS) reviewed Food and Nutrition Services Policy # PRO101 Food

Shermineh Jafarieh Nikki Pappas




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it was noted that two storage units were not labeled in accordance with policy. Neither included dates on the labels.

Receiving, Storage and Inventory Management, PROO1 Food Production to ensure consistent standards regarding dating and labeling. All members of the FNS department will be in-serviced and a post test administered. The Director of FNS and/or designee(s) will monitor compliance using the department daily cover, label, date quality control inspection. The Director of FNS and/or designee(s) will conduct a weekly inspection of all storage and refrigeration areas to monitor for compliance concurrent with corrective action. The data will be compiled in a Performance Improvement plan and reported to the Hospital Associate Administrator monthly and the Quality Committee quarterly.

Kelly Toth

PC.03.01.03: EP 7, Tier 3, A, R (pg 84 of 86): Before administering moderate or deep sedation or anesthesia, a licensed independent practitioner plans or concurs with the plan for sedation or anesthesia. EP 18, Tier 3, A, R (pg 84 of 86): For hospitals that use Joint Commission accreditation for deemed status purposes: A pre-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia within 48 hours prior to surgery or a procedure requiring anesthesia services.

Organization findings (pg 84 of 86): EP 18 There was no documentation of airway assessment in the pre-anesthesia evaluation.

The sections of the Anesthesia Service policies and procedures pertinent to completion of the anesthesia preoperative evaluation has been sent to all Anesthesia Service attending physicians and CRNAs at SFGH and an attestation of having read the passages will be required. The information was also presented at the CRNA staff meeting on 1/2/14 and at the Anesthesia faculty meeting of 1/9/14. Education materials were distributed on 1/6/14. An attestation of having read materials was completed by 1/13/14. The Anesthesia Service core leadership group are the

Todd May Jim Marks Shannon Thyne Robin Stackhouse Patty Coggan Ditas Hernandez




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champions for compliance with fully completing the anesthesia paperwork. The Department of Anesthesia billing personnel will monitor all preoperative evaluations for the presence of documentation of airway assessment and anesthetic plan for the period of 1 month, or until the completion rate is found to be > 99%. Thereafter, they will monitor all charts 1 day/month until the compliance is maintained for 3 consecutive months. An individual email will be sent to any practitioner with missing documentation and cc'd to the Chief and Vice Chief of Anesthesia Service.

Organization Findings: [CONTINUED] EP 7 No documented plan for anesthesia.

The sections of the Anesthesia Service policies and procedures pertinent to completion of the anesthesia preoperative evaluation has been sent to all Anesthesia Service attending physicians and CRNAs at SFGH and an attestation of having read the passages will be required. The information was also presented at the CRNA staff meeting on 1/2/14 and at the Anesthesia faculty meeting of 1/9/14. Education materials were distributed on 1/6/14. An attestation of having read materials was completed by 1/13/14. The Anesthesia Service core leadership group are the champions for compliance with fully completing the anesthesia paperwork. The Department of Anesthesia billing personnel will monitor all preoperative evaluations for the presence of documentation of airway assessment and anesthetic plan for the period of 1 month, or until the completion rate is found to be > 99%. Thereafter, they will monitor all charts 1 day/month until the compliance is maintained for 3

Todd May Jim Marks Shannon Thyne Robin Stackhouse Patty Coggan Ditas Hernandez




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consecutive months. An individual email will be sent to any practitioner with missing documentation and cc'd to the Chief and Vice Chief of Anesthesia Service.

RC.01.01.01, EP 19, Tier 4, C, R (pg 39 of 86): For hospitals that use Joint Commission accreditation for deemed status purposes: All entries in the medical record, including all orders, are timed.

Organization findings (pg 40 of 86): EP 19 Observation 1 The post procedure note was found not timed.

POST-PROCEDURE NOTE NOT TIMED/DATED: For any procedural areas that are not using an electronic post procedural note that meets all requirements, the "immediate postoperative note" that is currently part of the documentation for surgical procedures, will be used after all procedures. The Procedural Sedation Committee presented the deficiency findings and plan of action to the representatives of the procedural areas at the 1/13/14 Procedural Sedation Committee meeting. It will be the responsibility of the representatives to then bring this information back to their respective departments for implementation. Documentation of thorough completion of all paperwork (including time/date) will be added to the procedural sedation audit tool. The data will be trended over time and results reported back to the responsible chiefs of service. Procedural sedation data summaries will be presented to the committee on a quarterly basis, including both raw data and trends for each of the elements assessed. The target for compliance with timing and dating post procedure notes is 100%.

Jim Marks Shannon Thyne Todd May Philip Katzenberger Valerie Inouye

Observation 2 The post procedure note was found not dated and timed

POST-PROCEDURE NOTE NOT TIMED/DATED: For any procedural areas that are not using an electronic post procedural note that meets all requirements, the "immediate postoperative note" that is currently part of the documentation for surgical procedures, will be used after all procedures. The Procedural Sedation Committee presented the deficiency findings and plan of action to the





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representatives of the procedural areas at the 1/13/14 Procedural Sedation Committee meeting. It will be the responsibility of the representatives to then bring this information back to their respective departments for implementation. Documentation of thorough completion of all paperwork (including time/date) will be added to the procedural sedation audit tool. The data will be trended over time and results reported back to the responsible chiefs of service. Procedural sedation data summaries will be presented to the committee on a quarterly basis, including both raw data and trends for each of the elements assessed. The target for compliance with timing and dating post procedure notes is 100%.

Observation 3 While reviewing a record on 5E, it was noted that the nutritional assessment was not signed.

NUTRITIONAL ASSESSMENT: The Chief Clinical Dietitian in serviced all clinical nutrition staff regarding documentation requirements for nutritional assessments, including signatures, a outlined in Clinical Nutrition Policy # CL005, Clinical Nutrition: Medical Record Documentation. A post test was administered following the in-service. The Chief Clinical Dietitian and/or Clinical Nutrition Manager will audit 50 medical records per month as an ongoing Performance Improvement Plan. Numerator: All documented nutrition assessments signed by the Registered Dietitian. Denominator: 50 randomly selected patient medical records per month. Target goal is 100% of nutrition assessments are signed. The audit results will be reported to the Chief Nursing Officer monthly and the Quality Committee quarterly.

Kelly Toth Terry Dentoni

EP 19 no time noted on anesthesia pre-anesthesia evaluation. In addition, the attending physician had not dated or timed the authentication signature.

ANESTHESIA PRE-EVAL: The Chief of Anesthesia or designee will send the sections of the anesthesia policies and procedures pertinent to completion of the anesthesia preoperative evaluation to all anesthesia attending at SFGH. Attestation of having read the passages will be required. The





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information was presented at the 1/9/14 Anesthesia Faculty meeting 1/9/14. Education materials will be distributed by 1/13/14. Attestation of having read the materials will be required by 2/1/14. The anesthesia core leadership group will champion the need for compliance with fully completing the anesthesia paperwork. The Department of anesthesia billing personnel will monitor all preoperative evaluations for the presence of attending signature, time, and date for the period of 1 month, or until the completion rate is found to be > 99%. Thereafter, they will monitor all charts 1 day/month until the compliance is maintained for 3 consecutive months. An individual email will be sent to any practitioner with missing documentation and cc'd to the Chief and Vice Chief of Anesthesia.

Organization Findings: [CONTINUED] EP 19 an immediate post-procedure note had not been timed' by the authenticating provider.

POST-PROCEDURE NOTE NOT TIMED/DATED: For any procedural areas that are not using an electronic post procedural note that meets all requirements, the "immediate postoperative note" that is currently part of the documentation for surgical procedures, will be used after all procedures. The Procedural Sedation Committee presented the deficiency findings and plan of action to the representatives of the procedural areas at the 1/13/14 Procedural Sedation Committee meeting. It will be the responsibility of the representatives to then bring this information back to their respective departments for implementation. Documentation of thorough completion of all paperwork (including time/date) will be added to the procedural sedation audit tool. The data will be trended over time and results reported back to the responsible chiefs of service. Procedural sedation data summaries will be presented to the committee on a quarterly basis, including both raw data and trends for each of the elements assessed. The target for compliance with timing and dating post procedure notes is 100%.





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RC.02.01.03, EP 7, Tier 3, C, R, M (pg. 44 of 86): When a full operative or other high-risk procedure report cannot be entered immediately into the patient's medical record after the operation or procedure, a progress note is entered in the medical record before the patient is transferred to the next level of care. This progress note includes the name(s) of the primary surgeon(s) and his or her assistant(s), procedure performed and a description of each procedure finding, estimated blood loss, specimens removed, and postoperative diagnosis. Organization findings (pg 44 of 86): EP 7: Observation 1 It was found that the post-procedure note did not contain estimated blood loss and post-procedure diagnosis.

For any procedural areas that are not using an electronic post procedural note that meets all requirements, the Immediate postoperative note" that is currently part of the documentation for surgical procedures, will be used after all procedures. The Procedural Sedation Committee presented the deficiency findings and plan of action to the representatives of the procedural areas at the 1/13/14 Procedural Sedation Committee meeting. It will be the responsibility of the representatives to then bring this information back to their respective departments for implementation. Documentation of thorough completion of all paperwork (including estimated blood loss) will be added to the procedural sedation audit tool. The data will be trended over time and results reported back to the responsible chiefs of service. Procedural sedation data summaries will be presented to the Procedural Sedation Committee on a quarterly basis, including both raw data and trends for each of the elements assessed. The target goal for compliance with completing a post procedure note is 99%, the target goal for compliance with documentation of estimated blood loss is 95%. MOS: The Health Information Services Department will audit 100% of medical record post-procedure notes for four consecutive months to ensure compliance with the requirements that post procedure notes are documented in the medical

100% Jim Marks Robin Stackhouse Shannon Thyne Todd May Philip Katzenberger Valerie Inouye Terry Dentoni




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record, and that estimated blood loss and post procedure diagnosis are documented in the post procedure note. Numerator: all medical records with documented post-procedure notes, including estimated blood loss and post procedure diagnosis Denominator: all procedural cases

Observation 2 There was no documentation of immediate post procedure note.

For any procedural areas that are not using an electronic post procedural note that meets all requirements, the Immediate postoperative note" that is currently part of the documentation for surgical procedures, will be used after all procedures. The Procedural Sedation Committee presented the deficiency findings and plan of action to the representatives of the procedural areas at the 1/13/14 Procedural Sedation Committee meeting. It will be the responsibility of the representatives to then bring this information back to their respective departments for implementation. Documentation of thorough completion of all paperwork (including estimated blood loss) will be added to the procedural sedation audit tool. The data will be trended over time and results reported back to the responsible chiefs of service. Procedural sedation data summaries will be presented to the Procedural Sedation Committee on a quarterly basis, including both raw data and trends for each of the elements assessed. The target goal for compliance with completing a post procedure note is 99%, the target goal for compliance with documentation of estimated blood loss is 95%. MOS: The Health Information Services Department will audit 100% of medical record post-procedure notes for four consecutive months to ensure compliance with the requirements that





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post procedure notes are documented in the medical record, and that estimated blood loss and post procedure diagnosis are documented in the post procedure note. Numerator: all medical records with documented post-procedure notes, including estimated blood loss and post procedure diagnosis Denominator: all procedural cases

Organization Findings: [CONTINUED] Observation 3 Immediate post-procedure note did not contain post-procedural diagnosis and estimated blood loss

For any procedural areas that are not using an electronic post procedural note that meets all requirements, the Immediate postoperative note" that is currently part of the documentation for surgical procedures, will be used after all procedures. The Procedural Sedation Committee presented the deficiency findings and plan of action to the representatives of the procedural areas at the 1/13/14 Procedural Sedation Committee meeting. It will be the responsibility of the representatives to then bring this information back to their respective departments for implementation. Documentation of thorough completion of all paperwork (including estimated blood loss) will be added to the procedural sedation audit tool. The data will be trended over time and results reported back to the responsible chiefs of service. Procedural sedation data summaries will be presented to the Procedural Sedation Committee on a quarterly basis, including both raw data and trends for each of the elements assessed. The target goal for compliance with completing a post procedure note is 99%, the target goal for compliance with documentation of estimated blood loss is 95%. MOS: The Health Information Services Department will audit 100% of medical record post-procedure notes for four consecutive





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months to ensure compliance with the requirements that post procedure notes are documented in the medical record, and that estimated blood loss and post procedure diagnosis are documented in the post procedure note. Numerator: all medical records with documented post-procedure notes, including estimated blood loss and post procedure diagnosis Denominator: all procedural cases

RI.01.01.01, EP 5, Tier 4, C, R, M (pg. 51 of 86): The hospital respects the patient's right to and need for effective communication. (See also Rl.01.01.03, EP 1)

Organization findings (pg 51 of 86): EP 5 It was found that the advance directive information was given in English to a Spanish speaking patient (identified in a previous admission as Spanish speaking) and identified as requiring interpreter services in this admission. Due to small sample size and the diverse patient population, this will be scored as partial compliance

The Nurse Managers will re-educate their staff about the requirement that the Advanced Directive pamphlet given to patients are in the patient's primary language. MOS: The Nurse Manager or designee of the acute inpatient units will conduct ten weekly random concurrent observations of patient admissions for four consecutive months to ensure that the admission packet given to the patient contains the Advanced Directive pamphlet in the patient's primary language. Numerator: admission packets with AD pamphlets in patients’ primary language. Denominator: all admission packets. Audit results will be reported monthly to Nursing Quality Forum(NOF) and to Nursing Admin Forum (NAF).

Terry Dentoni Reggie Hortinela Juliet Palarca Diana Guevara Vanda Baptista Omar Carvallo Sharon Kwong

RI.01.03.01, EP 11, Tier 3, A, R (pg 52 of 86): The informed consent process includes a discussion about reasonable alternatives to the patient's proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effects related to the alternatives and the risks related to not receiving the proposed care, treatment, and services.




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Organization findings (pg 53 of 86): EP 11 It was found that there was no documentation of discussion encompassing risks related to not receiving the proposed care, treatment, and services in the informed consent.

The current "Consent for a Treatment or Procedure" form is being revised to add a field to the form for the provider to document the discussion encompassing risks related to not receiving the proposed care, treatment, and services e.g., doing nothing or choosing alternative options to the proposed care, treatment, and services. Once the form is implemented, hospital leadership will ensure that staff are in serviced on the revised form. Once the form is implemented, hospital leadership will audit for compliance with requirement that the provider document the discussion encompassing risks related to not receiving the proposed care, treatment, and services e.g., doing nothing or choosing alternative options to the proposed care, treatment, and services. The target goal is 95%. For procedures done in the operating room, the data will be reported to the OR Committee. For those performed in procedural areas, the data will be reported to the Procedural Sedation Committee.

Todd May Terri Dentoni Jeff Critchfield Jim Marks Robin Stackhouse Robyn Schanzenbach Patty Coggan Reggie Hortinela Juliet Palarca

EP 11 It was found on a second occasion, that there was no documentation of discussion encompassing risks related to not receiving the proposed care, treatment, and services in the informed consent.

The current "Consent for a Treatment or Procedure" form is being revised to add a field to the form for the provider to document the discussion encompassing risks related to not receiving the proposed care, treatment, and services e.g., doing nothing or choosing alternative options to the proposed care, treatment, and services. Once the form is implemented, hospital leadership will ensure that staff are in serviced on the revised form. Once the form is implemented, hospital leadership will audit for compliance with requirement that the provider document the discussion encompassing risks related to not





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receiving the proposed care, treatment, and services e.g., doing nothing or choosing alternative options to the proposed care, treatment, and services. The target goal is 95%. For procedures done in the operating room, the data will be reported to the OR Committee. For those performed in procedural areas, the data will be reported to the Procedural Sedation Committee.

EP 11 It was found on a third occasion, that there was no documentation of discussion encompassing risks related to not receiving the proposed care, treatment, and services in the informed consent.

The current "Consent for a Treatment or Procedure" form is being revised to add a field to the form for the provider to document the discussion encompassing risks related to not receiving the proposed care, treatment, and services e.g., doing nothing or choosing alternative options to the proposed care, treatment, and services. Once the form is implemented, hospital leadership will ensure that staff are in serviced on the revised form. Once the form is implemented, hospital leadership will audit for compliance with requirement that the provider document the discussion encompassing risks related to not receiving the proposed care, treatment, and services e.g., doing nothing or choosing alternative options to the proposed care, treatment, and services. The target goal is 95%. For procedures done in the operating room, the data will be reported to the OR Committee. For those performed in procedural areas, the data will be reported to the Procedural Sedation Committee.


TS.03.02.01, EP 2, Tier 4 C, D, R, M (pg 38 of 86): The hospital identifies, in writing, the materials and related instructions used to prepare or process tissues.

Organization findings (pg 38 of 86): EP 2 Noted that documentation related to the tendon tissue

Following the ICM survey, the Nurse Manager of Perioperative Nursing Service reviewed OR Policy

100% Terry Dentoni Patty Coggan




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preparation process included the 0.9% normal saline that was used to thaw and re-hydrate the tendon tissue. Documentation did not include the lot number or expiration date of the normal saline solution. Noted that documentation related to the tendon tissue preparation process included the 0.9% normal saline that was used to thaw and re-hydrate the tendon tissue. Documentation did not include the lot number of the normal saline solution used in the process.

29/Handling of Tissue Grafts/Human Allograft Tissue at staff meetings (day/evening shift) on 12/18/13. Staff reviewed policy and educational handout with examples of appropriate and inappropriate documentation. Policy review and handout completed on 12/18/13. The Nurse Manager of Perioperative Nursing Service will include the educational handout and policy review as part of annual/initial skill checklist for performance appraisal. The Nurse Manager of Perioperative Nursing Service will audit nursing documentation to ensure compliance with the policy requirements related to documentation of tissue preparation, including the lot number and expiration date of normal saline solution used to thaw and re-hydrate tendon tissue. MOS: The Nurse Manager of Perioperative Service or designee will audit 100% of the nursing documentation related to tendon tissue preparation processes for four consecutive months to ensure compliance with documentation requirements, including the lot number and expiration date of normal saline solution used to thaw and re-hydrate tendon tissue. Numerator: correctly documented tendon tissue preparation Denominator: all tendon tissues prepared for implantation

Kathy Ballou Ebi Fiebig Lawrence Nichols

UP .01.03.01 EP 2, Tier 4, A, R (pg 30 of 86): The time-out has the following characteristics: (NPSG) -It is standardized, as defined by the hospital -It is initiated by a designated member of the team -It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning




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Organization Findings (pg 30 of 86): It was observed by the surveyor that an immediate team member walked into the cath room in the middle of the time out process.

Following the ICM survey, the Director of Critical Care Nursing reviewed the findings with the Cardiac Cath lab nursing and provider staff. The Director reminded staff via read and sign memo of Admin Policy 21.07/Universal Protocol for Verification for Surgical or Invasive Procedures and Cardiac Lab Policy 4.0/Guidelines for Coronary Angiography regarding time-out requirements and procedures. The Nurse Manager or designee will randomly observe universal protocol/time out procedures in the Cardiac Cath lab monthly to ensure staff compliance with policy requirements. The Chief of Anesthesia Service, in collaboration with the Chief Medical Officer, is standardizing "Time Out" procedures to be implemented everywhere within SFGH wherever anesthesia /procedural sedation is administered. The current Operating Room time-out procedure is the prototype for standardization. Admin Policy 19.08/Procedural Sedation: Moderate & Deep is being revised to reflect the standardization of the time-out procedure. The current time out protocol was be presented at the 1/13/14 Procedural Sedation Committee meeting. A report back by sedation committee members on actions taken to meet compliance standards is anticipated by February 10, 2014. Documentation of compliance with all elements of the standardized time out protocol will be added to the procedural sedation audit tool. The data will be trended over time and results reported back to the responsible

Shannon Thyne Jennie Farr Todd May Terry Dentoni Jim Marks Tom Holton Janet Kosewic




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chiefs of service. Procedural sedation data summaries will be presented to the Procedural Sedation Committee on a quarterly basis, including both raw data and trends for each of the elements assessed. The goal for compliance with the standardized time out process is > 95%.

WT.01.01.01, EP 6, Tier 3, C, R, M (pg. 20 of 86): Written policies, procedures, and manufacturers' instructions for waived testing are followed. (See also WT.04.01.01, EPs 3-5). Note: Manufacturers' recommendations and suggestions are surveyed as requirements

Organization Findings (pg 20 of 86): EP 6. Observation 1 During a visit to the medication room on 7B, it was noted that one set of High and Low reagents for testing the Glucometer were expired according to hospital policy.

The Point of Care Testing (POCT) Policy on Blood Glucose Monitoring was revised to require that open high and low reagent containers for testing the Glucometer are labeled with an opening date, and an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. The policy revision was approved by the POCT Committee and the responsible CLIA Director on 1/3/14. The POCT Coordinator notified the nurse managers of the sites where POCT blood glucose monitoring is performed about the policy revision and directed the nurse managers to notify all staff performing POCT glucose measurements for patient care about the policy revision. Additionally, the nurse managers of the sites where POCT blood glucose monitoring is performed were directed to check their open high and low reagent containers to ensure that they were labeled with an opening date, and an expiration date based on the opening date, and that the labeling was legible and protected from accidental removal. POCT service staff will conduct monthly audits of POCT blood glucose monitoring sites to verify ongoing compliance with the requirement that open high and low reagent

95% Mary Clancy Clay Hooper Terry Dentoni Ebi Fiebig Kathy Ballou




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containers for testing the Glucometer are labeled with an opening date, with an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. MOS: POCT service staff will audit 100% of open high and low reagent containers for testing the Glucometer for four consecutive months to ensure compliance with the policy requirement that the containers are labeled with an opening date, and an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. The audit results will be reported monthly to the POCT Committee and to the CLIA Director of the Clinical Laboratory

Observation 2 During a visit to the medication room on 7B it was noted that one set of High and Low reagents for the testing the Glucometer were missing the open and expiration dates - there was some small evidence of red ink, but the dates were completely obliterated. This was also noted with reagents on 5E

The Point of Care Testing (POCT) Policy on Blood Glucose Monitoring was revised to require that open high and low reagent containers for testing the Glucometer are labeled with an opening date, and an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. The policy revision was approved by the POCT Committee and the responsible CLIA Director on 1/3/14. The POCT Coordinator notified the nurse managers of the sites where POCT blood glucose monitoring is performed about the policy revision and directed the nurse managers to notify all staff performing POCT glucose measurements for patient care about the policy revision. Additionally, the nurse managers of the sites where POCT blood glucose monitoring is performed were directed to check their open high and low reagent containers to ensure that they were labeled with an opening date, and an expiration date based





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on the opening date, and that the labeling was legible and protected from accidental removal. POCT service staff will conduct monthly audits of POCT blood glucose monitoring sites to verify ongoing compliance with the requirement that open high and low reagent containers for testing the Glucometer are labeled with an opening date, with an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. MOS: POCT service staff will audit 100% of open high and low reagent containers for testing the Glucometer for four consecutive months to ensure compliance with the policy requirement that the containers are labeled with an opening date, and an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. The audit results will be reported monthly to the POCT Committee and to the CLIA Director of the Clinical Laboratory

Observation 3 During a visit to the medication room on 7L. it was noted that the open high and low reagents for the testing the Glucometer had an opening date but no expiration date based on the opening date.

The Point of Care Testing (POCT) Policy on Blood Glucose Monitoring was revised to require that open high and low reagent containers for testing the Glucometer are labeled with an opening date, and an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. The policy revision was approved by the POCT Committee and the responsible CLIA Director on 1/3/14. The POCT Coordinator notified the nurse managers of the sites where POCT blood glucose monitoring is performed about the policy revision and directed the nurse managers





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to notify all staff performing POCT glucose measurements for patient care about the policy revision. Additionally, the nurse managers of the sites where POCT blood glucose monitoring is performed were directed to check their open high and low reagent containers to ensure that they were labeled with an opening date, and an expiration date based on the opening date, and that the labeling was legible and protected from accidental removal. POCT service staff will conduct monthly audits of POCT blood glucose monitoring sites to verify ongoing compliance with the requirement that open high and low reagent containers for testing the Glucometer are labeled with an opening date, with an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. MOS: POCT service staff will audit 100% of open high and low reagent containers for testing the Glucometer for four consecutive months to ensure compliance with the policy requirement that the containers are labeled with an opening date, and an expiration date based on the opening date, and that the labeling is legible and protected from accidental removal. The audit results will be reported monthly to the POCT Committee and to the CLIA Director of the Clinical Laboratory

Documents

San Francisco General Hospital & Trauma Center The … 11/201… · San Francisco General Hospital & Trauma Center The Joint Commission, ICM OPTION 2 SURVEY COMPREHENSIVE QUALITY